2017 AHA心肺复苏指南：成人基础生命支持和心肺复苏质量.

CLINICALSTATEMENTSANDGUIDELINESCirculation.2017;136:00–00.DOI:10.1161/CIR.0000000000000539TBDTBD,2017e1ABSTRACT:Cardiopulmonaryresuscitationisalifesavingtechniqueforvictimsofsuddencardiacarrest.Despiteadvancesinresuscitationscience,basiclifesupportremainsacriticalfactorindeterminingoutcomes.TheAmericanHeartAssociationrecommendationsforadultbasiclifesupportincorporatethemostrecentlypublishedevidenceandserveasthebasisforeducationandtrainingforlaypeopleandhealthcareproviderswhoperformcardiopulmonaryresuscitation.In2015,theAmericanHeartAssociation(AHA)publishedthe“2015AHAGuide-linesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCare”includingrecommendationsforadultbasiclifesupport(BLS)andcardiopul-monaryresuscitation(CPR)quality.1Thatguidelinesupdatewasbasedonthe“2015InternationalConsensusonCardiopulmonaryResuscitationandEmergencyCardio-vascularCareScienceWithTreatmentRecommendations”(CoSTR)developedbytheInternationalLiaisonCommitteeonResuscitation(ILCOR).2Asplanned,ILCORisnowtransitioningtoaprocessofcontinuousevidenceevaluation,withtheintenttoissueupdatedsystematicreviewsandCoSTRstatementswhenpromptedbythepublica-tionofnewevidence.Adescriptionoftheevidencereviewprocessandaglossaryoftermsareavailableinthe2017BLSCoSTRsummary.3Whenindicated,theAHAwillpublishfocusedupdatesforguidelinesrelatedtotheareasreviewedbyILCOR.ThefirsttopicsselectedbyILCORaspartofthecontinuousevidenceevaluationprocessarerelatedtoBLS,includingdispatch-assistedCPR,theuseofcontinuousversusinterruptedchestcompressionsbyemergencymedicalservices(EMS)provid-ers,andtheuseofchestcompression–only(hands-only)CPRversusCPRusingchestcompressionswithventilationinboththein-hospitalandout-of-hospitalsettings.Theevidenceevaluatedincludedstudiesusedtosupportthe2015CoSTR2andnewliteraturepublishedsince2015.Itisimportanttonotethatthisfocusedupdatecoversonlythosetopicsad-dressedbyILCOR’snewcontinuousevidenceevaluationprocessasof2017.TheILCORsystematicreviewsusetheGradingofRecommendationsAssessment,Devel-opment,andEvaluationmethodologyanditsassociatednomenclatureforstrengthofrecommendationandlevelofevidence.TheexpertwritinggroupforthisadultBLS–focusedupdatereviewedthestudiescitedinthe2017BLSCoSTRsummary3andcarefullyconsideredtheILCORconsensusrecommendationsinlightofthestructureandresourcesoftheout-of-hospitalandin-hospitalresuscitationsystemsthatuseAHAguidelines.Inaddition,thewritinggroupdeterminedclassesofrec-ommendationandlevelsofevidenceaccordingtothemostrecentreportbytheAmericanCollegeofCardiology/AHAonclinicalpracticeguidelines(Table)4byusingtheprocessdetailedinpart2ofthe2015guidelinesupdate.5Allotherrecommen-dationsandalgorithmspublishedinthe2015guidelinesupdate1andthe“2010MonicaE.Kleinman,MD,ChairZacharyD.Goldberger,MD,MSc,FAHAThomasRea,MD,MPHRobertA.Swor,DOBentleyJ.Bobrow,MD,FAHAErinE.Brennan,MD,MMEdMarkTerry,MPA,NRPRobinHemphill,MD,MPHRaúlJ.Gazmuri,MD,PhDMaryFranHazinski,MSN,RN,FAHAAndrewH.Travers,MD,MSc2017AmericanHeartAssociationFocusedUpdateonAdultBasicLifeSupportandCardiopulmonaryResuscitationQualityAnUpdatetotheAmericanHeartAssociationGuidelinesforCardio­pulmonaryResuscitationandEmergencyCardiovascularCare©2017AmericanHeartAssociation,Inc.KeyWords:AHAScientificStatements◼basiclifesupport◼cardiopulmonaryresuscitation◼emergencytreatmentAHAFOCUSEDUPDATEbyguestonNovember8,2017http://circ.ahajournals.org/DownloadedfromKleinmanetalTBDTBD,2017Circulation.2017;136:00–00.DOI:10.1161/CIR.0000000000000539e2AmericanHeartAssociationGuidelinesforCardiopul-monaryResuscitationandEmergencyCardiovascularCare”6remaintheofficialrecommendationsoftheAHAEmergencyCardiovascularCareScienceSubcommitteeandwritinggroups.RecommendationsforeachtopicaddressedinthisadultBLS–focusedupdateareclassifiedasfollows:1.Unchangedrecommendations2.Updatedrecommendations(maybeupdatedinwording,class,levelofevidence,oranycombina-tionofthese)AttherequestoftheAHATrainingNetwork,wehavealsoclarifiedthedescriptionsoflayrescuersasfollows:1.Untrained2.Trainedinchestcompression–onlyCPRTable.ACC/AHARecommendationSystem:ApplyingClassofRecommendationandLevelofEvidencetoClinicalStrategies,Interventions,Treatments,orDiagnosticTestinginPatientCare*(UpdatedAugust2015)byguestonNovember8,2017http://circ.ahajournals.org/DownloadedfromAdultBLSandCPRQuality:FocusedUpdatetotheAHAGuidelinesforCPRandECCCirculation.2017;136:00–00.DOI:10.1161/CIR.0000000000000539TBDTBD,2017e3CLINICALSTATEMENTSANDGUIDELINES3.TrainedinCPRusingchestcompressionsandven-tilation(rescuebreaths)DISPATCH­ASSISTEDCPRThe2017BLSCoSTRsummary3andsystematicreviewconsideredinstructionsfordispatch-assistedchestcom-pression–onlyCPRforout-of-hospitalcardiacarrest(OHCA).2017SummaryofEvidenceNonewstudieswerereviewedforthistopic.2017Recommendation—Updated1.Werecommendthatwhendispatchers’instructionsareneeded,dispatchersshouldprovidechestcompression–onlyCPRinstruc­tionstocallersforadultswithsuspectedOHCA(ClassI;LevelofEvidenceC-LD).BYSTANDERCPRThe2017BLSCoSTRsummary3andsystematicreviewcomparedbystanderuseofchestcompression–onlyCPRwithCPRusingchestcompressionsandventilation(rescuebreaths).2017SummaryofEvidenceIwamietal7examinedtheinfluenceofJapan’snation-widedisseminationofrecommendationsforcontinu-ouschestcompressionCPRforlayrescuers,includingdispatcher-assistedCPR,atatimewhenCPRguidelinesrecommendedcompressionsplusventilation(rescuebreaths)ataratioof30compressionsto2breaths.Theunadjustedanalysisshowedthatnationwidetheinter-ventionwasassociatedwithimprovedbystanderCPRratesandincreasedsurvival.However,inanunadjustedanalysisofcrudedata,patientsreceivingcontinuouschestcompressionshadalowerrateofreturnofspon-taneouscirculation(oddsratio,0.80;95%confidenceinterval[CI],0.78–0.82),worse1-monthsurvival(oddsratio,0.75;95%CI,0.73–0.78),andworse1-monthsurvivalwithgoodneurologicaloutcome(oddsratio,0.72;95%CI,0.69–0.76)comparedwiththosereceiv-ingCPRusingaratioof30compressionsto2breaths.2017Recommendations—Updated1.ForadultsinOHCA,untrainedlayrescuersshouldprovidechestcompression–onlyCPRwithorwithoutdispatcherassistance(ClassI;LevelofEvidenceC-LD).2.Forlayrescuerstrainedinchestcompres­sion–onlyCPR,werecommendtheyprovidechestcompression–onlyCPRforadultsinOHCA(ClassI;LevelofEvidenceC-LD).3.ForlayrescuerstrainedinCPRusingchestcompressionsandventilation(rescuebreaths),itisreasonabletoprovideventilation(res­cuebreaths)inadditiontochestcompres­sionsfortheadultinOHCA(ClassIIa;LevelofEvidenceC-LD).EMS­DELIVEREDCPRThe2017BLSCoSTRsummary3andsystematicreviewconsideredtheuseofinterruptedversuscontinuouschestcompressionswhenEMSprovidersperformedCPRusingchestcompressionsandventilationbeforeplacementofanadvancedairway.2017SummaryofEvidenceTheResuscitationOutcomesConsortiumconductedacluster-randomizedcrossovertrialofadultswithEMS-treatednontraumatic,nonasphyxialcardiacarrest.8Allpatientsreceivedpositive-pressureventilationduringCPRbeforeplacementofanadvancedairway(supraglotticairwayortrachealtube).Intheinterventiongroup,chestcompressionswereprovidedcontinuouslyandventilationwasdeliveredasynchronouslyatarateof10breathsperminutewithoutpausingchestcompressions.Inthecon-trolgroup,chestcompressionswereinterruptedforven-tilationataratioof30compressionsto2breaths.Thestudyanalyzed23711adultswithcardiacarrestusingaprimaryoutcomeofsurvivaltohospitaldischarge.Overall,therewasnosignificantdifferenceinoutcomebetweenpatientsintheinterventiongroupandthoseinthecontrolgroup,withsurvivaltodischargeof9.0%and9.7%,re-spectively(adjusteddifference,−0.7;95%CI,−1.5to0.1;P=0.07).Likewise,therewasnodifferenceinsurvivalwithgoodneurologicaloutcome(7.0%versus7.7%;adjusteddifference,−0.6;95%CI,−1.4to0.1;P=0.09).2017Recommendations—Updated1.Werecommendthatbeforeplacementofanadvancedairway(supraglotticairwayortra­chealtube),EMSprovidersperformCPRwithcyclesof30compressionsand2breaths(ClassIIa;LevelofEvidenceB-R).Asanalternative,itisreasonableforEMSproviderstoperformCPRincyclesof30compressionswith2breathswithoutinterruptingchestcompressionstogivebreaths(ClassIIa;LevelofEvidenceB-R).ItmaybereasonableforEMSproviderstousearateof10breathsperminute(1breathevery6byguestonNovember8,2017http://circ.ahajournals.org/DownloadedfromKleinmanetalTBDTBD,2017Circulation.2017;136:00–00.DOI:10.1161/CIR.0000000000000539e4seconds)toprovideasynchronousventilationduringcontinuouschestcompressionsbeforeplacementofanadvancedairway(ClassIIb;LevelofEvidenceC-LD).2.Theseupdatedrecommendationsdonotprecludethe2015recommendationthatareasonablealternativeforEMSsystemsthathaveadoptedbundlesofcareistheinitialuseofminimallyinterruptedchestcompressions(ie,delayedventilation)forwitnessedshock­ableOHCA(ClassIIb;LevelofEvidenceC-LD).CPRFORCARDIACARRESTThe2017BLSCoSTRsummary3andsystematicreviewconsideredtheuseofcontinuousversusinterruptedchestcompressionsafterplacementofanadvancedairwayinthehospitalsetting.2017SummaryofEvidenceNonewstudieswerereviewedforthistopic.2017Recommendations—Updated1.Wheneveranadvancedairway(trachealtubeorsupraglotticdevice)isinserteddur­ingCPR,itmaybereasonableforproviderstoperformcontinuouscompressionswithpos­itive­pressureventilationdeliveredwithoutpausingchestcompressions(ClassIIb;LevelofEvidenceC-LD).Itmaybereasonablefortheprovidertodeliver1breathevery6sec­onds(10breathsperminute)whilecontinu­ouschestcompressionsarebeingperformed(ClassIIb;LevelofEvidenceC-LD).CHESTCOMPRESSION–TO–VENTILATIONRATIOThe2017BLSCoSTRsummary3andsystematicreviewconsideredthecompression-to-ventilationratioforadultBLS.2017SummaryofEvidenceNonewstudieswerereviewedforthistopic.2017Recommendation—Updated1.ItisreasonableforrescuerstrainedinCPRusingchestcompressionsandventilation(rescuebreaths)toprovideacompression­to­ventilationratioof30:2foradultsincar­diacarrest(ClassIIa;LevelofEvidenceC-LD).2017FocusedUpdate:AdultBLSRecommendationsYearLastReviewedTopicRecommendationComments2017Dispatch-assistedCPRWerecommendthatwhendispatchers’instructionsareneeded,dispatchersshouldprovidechestcompression–onlyCPRinstructionstocallersforadultswithsuspectedOHCA(ClassI;LevelofEvidenceC-LD).Updatedfor20172017BystanderCPR:untrainedlayrescuerForadultsinOHCA,untrainedlayrescuersshouldprovidechestcompression–onlyCPRwithorwithoutdispatcherassistance(ClassI;LevelofEvidenceC-LD).Updatedfor20172017BystanderCPR:layrescuertrainedinchestcompression–onlyCPRForlayrescuerstrainedinchestcompression–onlyCPR,werecommendtheyprovidechestcompression–onlyCPRforadultsinOHCA(ClassI;LevelofEvidenceC-LD).Updatedfor20172017BystanderCPR:layrescuerstrainedinCPRusingchestcompressionsandventilation(rescuebreaths)ForlayrescuerstrainedinCPRusingchestcompressionsandventilation(rescuebreaths),itisreasonabletoprovideventilation(rescuebreaths)inadditiontochestcompressionsfortheadultinOHCA(ClassIIa;LevelofEvidenceC-LD).Updatedfor20172017EMS-deliveredCPRfocusonchestcompression–to–ventilationratiosWerecommendthatbeforeplacementofanadvancedairway(supraglotticairwayortrachealtube),EMSprovidersperformCPRwithcyclesof30compressionsand2breaths(ClassIIa;LevelofEvidenceB-R).Updatedfor20172017EMS-deliveredCPRfocusonchestcompression–to–ventilationratiosAsanalternative,itisreasonableforEMSproviderstoperformCPRincyclesof30compressionswith2breathswithoutinterruptingchestcompressionstogivebreaths(ClassIIa;LevelofEvidenceB-R).Updatedfor20172017EMS-deliveredCPRfocusonchestcompression–to–ventilationratiosItmaybereasonableforEMSproviderstousearateof10breathspermin(1breathevery6s)toprovideasynchronousventilationduringcontinuouschestcompressionsbeforeplacementofanadvancedairway(ClassIIb;LevelofEvidenceC-LD).Updatedfor20172017EMS-deliveredCPRfocusonchestcompression–to–ventilationratiosTheseupdatedrecommendationsdonotprecludethe2015recommendationthatareasonablealternativeforEMSsystemsthathaveadoptedbundlesofcareistheinitialuseofminimallyinterruptedchestcompressions(ie,delayedventilation)forwitnessedshockableOHCA(ClassIIb;LevelofEvidenceC-LD).Updatedfor2017(Continued)byguestonNovember8,2017http://circ.ahajournals.org/DownloadedfromAdultBLSandCPRQuality:FocusedUpdatetotheAHAGuidelinesforCPRandECCCirculation.2017;136:00–00.DOI:10.1161/CIR.0000000000000539TBDTBD,2017e5CLINICALSTATEMENTSANDGUIDELINESFOOTNOTESTheAmericanHeartAssociationmakeseveryefforttoavoidanyactualorpotentialconflictsofinterestthatmayariseasaresultofanoutsiderelationshiporapersonal,professional,orbusinessinterestofamemberofthewritingpanel.Specifically,allmem-bersofthewritinggrouparerequiredtocompleteandsubmitaDisclosureQuestionnaireshowingallsuchrelationshipsthatmightbeperceivedasrealorpotentialconflictsofinterest.ThisfocusedupdatewasapprovedbytheAmericanHeartAssociationScienceAdvisoryandCoordinatingCommitteeonSeptember15,2017,andtheAmericanHeartAssociationExecutiveCommitteeonOctober9,2017.Acopyofthedoc-umentisavailableathttp://professional.heart.org/statementsbyusingeither“SearchforGuidelines&Statements”orthe“BrowsebyTopic”area.Topurchaseadditionalreprints,call843-216-2533ore-mailkelle.ramsay@wolterskluwer.com.TheAmericanHeartAssociationrequeststhatthisdoc-umentbecitedasfollows:KleinmanME,GoldbergerZD,ReaT,SworRA,BobrowBJ,BrennanEE,TerryM,Hemp-hillR,GazmuriRJ,HazinskiMF,TraversAH.2017Ameri-canHeartAssociationfocusedupdateonadultbasiclifesupportandcardiopulmonaryresuscitationquality:anup-datetotheAmericanHeartAssociationguidelinesforcar-diopulmonaryresuscitationandemergencycardiovascularcare.Circulation.2017;136:eXXX–eXXX.DOI:10.1161/CIR.0000000000000539.ExpertpeerreviewofAHAScientificStatementsisconduct-edbytheAHAOfficeofScienceOperations.FormoreonAHAstatementsandguidelinesdevelopment,visithttp://professional.heart.org/statements.Selectthe“Guidelines&Statements”drop-downmenu,thenclick“PublicationDevelopment.”Permissions:Multiplecopies,modification,alteration,en-hancement,and/ordistributionofthisdocumentarenotpermit-tedwithouttheexpresspermissionoftheAmericanHeartAsso-ciation.Instructionsforobtainingpermissionarelocatedathttp://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp.Alinktothe“CopyrightPermissionsRequestForm”appearsontherightsideofthepage.Circulationisavailableathttp://circ.ahajournals.org.2017CPRforcardiacarrestwithanadvancedairwayWheneveranadvancedairway(trachealtubeorsupraglotticdevice)isinsertedduringCPR,itmaybereasonableforproviderstoperformcontinuouscompressionswithpositive-pressureventilationdeliveredwithoutpausingchestcompressions(ClassIIb;LevelofEvidenceC-LD).Updatedfor20172017CPRforcardiacarrestwithanadvancedairwayAfterplacementofanadvancedairway,itmaybereasonablefortheprovidertodeliver1breathevery6s(10breathspermin)whilecontinuouschestcompressionsarebeingperformed(ClassIIb;LevelofEvidenceC-LD).Unchangedfor20172017Chestcompression–to–ventilationratioItisreasonableforrescuerstrainedinCPRusingchestcompressionsandventilation(rescuebreaths)toprovideacompression-to-ventilationratioof30:2foradultsincardiacarrest(ClassIIa;LevelofEvidenceC-LD).Updatedfor2017BLSindicatesbasiclifesupport;CPR,cardiopulmonaryresuscitation;EMS,emergencymedicalservices;andOHCA,out-of-hospitalcardiacarrest.DISCLOSURESWritingGroupDisclosuresWritingGroupMemberEmploymentResearchGrantOtherResearchSupportSpeakers’Bureau/HonorariaExpertWitnessOwnershipInterestConsultant/AdvisoryBoardOtherMonicaE.KleinmanChildren’sHospitalBostonNoneNoneNoneNoneNoneNoneNoneErinE.BrennanKingstonResuscitationInstitute(researchgrantinCPReducation)*NoneNoneNoneNoneNoneNoneNoneBentleyJ.BobrowArizonaDepartmentofHealthServicesNoneNoneNoneNoneNoneNoneNone(Continued)2017FocusedUpdate:AdultBLSRecommendations(Continued)YearLastReviewedTopicRecommendationCommentsbyguestonNovember8,2017http://circ.ahajournals.org/DownloadedfromKleinmanetalTBDTBD,2017Circulation.2017;136:00–00.DOI:10.1161/CIR.0000000000000539e6RaúlJ.GazmuriRosalindFranklinUniversityofMedicineandScienceDePaul-RosalindFranklinUniversityCollaborativePilotResearchGrantProgram(basicscienceresearch;studymechanismsbywhichcyclophilin-Dmodulatestranscriptionofmitochondrialgenes)†;JamesR.&HelenD.RussellInstituteforResearch&Innovation:SmallResearchGrantsProgram(basicscienceresearch;preventionofoxidativeinjurytotheneonatalheart)*;DepartmentofDefenseUSArmyMedicalResearchandMaterialCommand(translationalresearch:sustainedV1Areceptoractivationforprolongedhemodynamicsupportandneurologicalprotectionafternoncompressiblehemorrhageandtraumaticbraininjury)†;ZollMedicalCorp(translationalresearch:AMSAtoguideshockdeliveryinaswinemodelofventricularfibrillationandclosedchestresuscitation)†NoneNoneNoneNoneNoneNoneZacharyD.GoldbergerUniversityofWashingtonNoneNoneNoneNoneNoneNoneNoneMaryFranHazinskiVanderbiltUniversityNoneNoneNoneNoneNoneAmericanHeartAssociationECC†NoneRobinHemphillVeteransHealthAdministrationNoneNoneNoneNoneNoneNoneNoneThomasReaUniversityofWashingtonNoneNoneNoneNoneNoneNoneNoneRobertA.SworWilliamBeaumontHospitalNoneNoneNoneNoneNoneNoneNoneMarkTerryJohnsonCountyMED-ACTNoneNoneNoneNoneNoneNoneNoneAndrewH.TraversEmergencyHealthServices,NovaScotia(Canada)NoneNoneNoneNoneNoneNoneNoneThistablerepresentstherelationshipsofwritinggroupmembersthatmaybeperceivedasactualorreasonablyperceivedconflictsofinterestasreportedontheDisclosureQuestionnaire,whichallmembersofthewritinggrouparerequiredtocompleteandsubmit.Arelationshipisconsideredtobe“significant”if(a)thepersonreceives$10000ormoreduringany12-monthperiod,or5%ormoreoftheperson’sgrossincome;or(b)thepersonowns5%ormoreofthevotingstockorshareoftheentity,orowns$10000ormoreofthefairmarketvalueoftheentity.Arelationshipisconsideredtobe“modest”ifitislessthan“significant”undertheprecedingdefinition.*Modest.†Significant.ReviewerDisclosuresReviewerEmploymentResearchGrantOtherResearchSupportSpeakers’Bureau/HonorariaExpertWitnessOwnershipInterestConsultant/AdvisoryBoardOtherLorrelE.BrownUniversityofLouisvilleNoneNoneNoneNoneNoneNoneNoneTomasDrabekUniversityofPittsburghNoneNoneNoneNoneNoneNoneNoneJudithFinnCurtinUniversity(Australia)NHMRC(directoroftheAustralianResuscitationOutcomesConsortium[Aus-ROC],anNHMRCCentreofResearchExcellence)*NoneNoneNoneNoneNoneNoneWritingGroupDisclosuresContinuedWritingGroupMemberEmploymentResearchGrantOtherResearchSupportSpeakers’Bureau/HonorariaExpertWitnessOwnershipInterestConsultant/AdvisoryBoardOther(Continued)byguestonNovember8,2017http://circ.ahajournals.org/DownloadedfromAdultBLSandCPRQuality:FocusedUpdatetotheAHAGuidelinesforCPRandECCCirculation.2017;136:00–00.DOI:10.1161/CIR.0000000000000539TBDTBD,2017e7CLINICALSTATEMENTSANDGUIDELINESFredrikFolkeGentofteUniversityHospital,Hellerup(Denmark)NoneNoneNoneNoneNoneNoneNoneGuillaumeGeriAmbroiseParéHospital(France)NoneNoneNoneNoneNoneNoneNoneJamesT.NiemannHarbor–UCLAMedicalCenterNoneNoneNoneNoneNoneNoneNoneThistablerepresentstherelationshipsofreviewersthatmaybeperceivedasactualorreasonablyperceivedconflictsofinterestasreportedontheDisclosureQuestionnaire,whichallreviewersarerequiredtocompleteandsubmit.Arelationshipisconsideredtobe“significant”if(a)thepersonreceives$10000ormoreduringany12-monthperiod,or5%ormoreoftheperson’sgrossincome;or(b)thepersonowns5%ormoreofthevotingstockorshareoftheentity,orowns$10000ormoreofthefairmarketvalueoftheentity.Arelationshipisconsideredtobe“modest”ifitislessthan“significant”undertheprecedingdefinition.*Modest.REFERENCES1.KleinmanME,BrennanEE,GoldbergerZD,SworRA,TerryM,BobrowBJ,GazmuriRJ,TraversAH,ReaT.Part5:adultbasiclifesupportandcardio-pulmonaryresuscitationquality:2015AmericanHeartAssociationguide-linesupdateforcardiopulmonaryresuscitationandemergencycardio-vascularcare.Circulation.2015;132(suppl2):S414–S435.doi:10.1161/CIR.000000